A 53 year old man came to the OP two days ago with stomach pain and chest pain

 The patient's and his attender's consent was obtained, following which detailed history was taken and examination was performed.

HOPI

The patient was apparently asymptomatic two days ago when he developed pain and discomfort in the stomach while on a job (he is an electrician by profession) which was sudden in onset and quickly progressed to severe discomfort which was fluctuating between the chest and abdomen. He was climbing an electric pole when this episode of discomfort occurred. The discomfort was associated with anxiousness and mild shortness of breath.

The pain was relieved on medication. 

Patient recollects having similar complaints in the past 6 years. The episodes of "gas trouble" were often aggravated by certain foods (meat, eggs and tamarind) and consumption of alcohol along with reduced food consumption. He found relief after taking medicines like Pantop and Rabalkem. 

The patient supposedly started consuming alcohol (90 ml/day) 3 months ago after abstaining from it for almost a decade. He mentions financial trouble which may have contributed to his psychological stress. Problem of dependency is suspected.

There is no history of vomiting, diarrhea or fever.

No history of cough, frothy urine, melena, heart palpitations etc.

No history of weight loss. He has gained 6-7 kgs in the past year.


Past history

Patient had undergone angioplasty in the year 2009. He hasn't properly taken his medications and hasn't been regular for his check ups. 

Patient has had gas trouble since six years. He was a known alcoholic for 10 years before he quit. He has started consuming alcohol again three months ago.

He had hand cramping three years ago.

Patient is not a diabetic. No history of hypertension, asthma, TB or epilepsy present.


Family history

Both parents died of natural causes. Mother was suffering with paralysis before death.

No other significant family history.


Personal history

Patient has had reduced appetite since one year and hasn't eaten at all since the past three days.

He consumes a mostly vegetarian diet and avoids certain foods which aggravate his gas trouble.

He takes medication for sleep (Alzolam 0.25mg).

He has mild constipation. No history of burning micturition or bladder control, etc.

He has been vaccinated.

He passed tenth grade after which he started working as a driver at the age of 20. Around the same time he developed habit of drinking alcohol as well as smoking. He quit after a year on being scolded by family members. 10 years later he resumed alcohol intake. He continued to consume upto 180 ml/day for the nest 10 years. 


Surgical history

Underwent angioplasty in 2009. 


Medical history

Pantoprazole 40 mg occasionally

Alzolam (Benzodiazepine) 0.25 mg every night for sleep.

Levosulpiride and Rabeprazole (for GERD) to relieve symptoms of gas trouble.


General examination

Patient was conscious, coherent and cooperative at the time of examination. He was well oriented to person, place and time.

Patient was moderately built and moderately nourished.

No signs of pallor, icterus, clubbing or cyanosis. No generalized lymphadenopathy. No pedal edema. (He mentions that his feet were swollen 3-4 days ago)















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